Interrelation among Medicine, Ethics and the Law - Case Study Example

The Court of Appeal in England confirmed a lower court's ruling that doctors could perform an operation to separate recently born conjoined twins. The doctors were of the opinion that this might save one of the babies while the other would lose its life. They further stated that if the operation was not performed, then it could result in the death of both these twins within months of their birth. The parents, being devout Roman Catholics, believed that it was absolutely wrong to kill one of their babies, even to save the life of the other. This case has thrown up a lot of medical, ethical and legal issues. In the sequel, the medical and ethical issues will be glossed over en passant, while the legal issues will be discussed in somewhat greater detail. The medical issues involved are that, Jodie one of these conjoined twins is a bright alert baby with a functioning heart and lungs and her legs, though set wide apart can be rectified by surgery and on separation from Mary, the other twin in this conjoined pair, Jodie would be able to lead a relatively normal life, for instance walking unaided, attending school and being able to have children. However, in respect of Mary, her face is deformed and more importantly her heart and lung functions are effectively none. Mary's existence is solely dependent on her physical attachment to Jodie. In other words, separation for Jodie means the expectation of a normal life and unfortunately, for Mary it means death1. The medical classification of this type of conjoined twins is termed as Ischiopagus tetrapus and in such twins is a fusion at the pelvic level often with sharing of genitourinary structures, rectum and liver. In other words, the medical position was that an operation performed with the intent of separating the twins was imminent and this would certainly result in the death of Mary. From the ethical point of view, the Manchester team, which had never succeeded in separating Siamese twins, went to court to overturn the parents' refusal, without seeking a second medical opinion from the Great Ormond Street team, which had the requisite experience. The parents were not at all in agreement with the decision of the doctors. Further, the family were Italians who in order to avail themselves of the better medical facilities available, had come to England. A Catholic hospital in Italy had consented to provide care in accordance with the parents' wishes. In a number of analogous cases the world over, surgical teams had refused to operate because they could not morally accept the killing of one of the conjoined twins for the benefit of another. As an example, the Loyola University Medical Centre in Chicago, refused to operate on twins sharing a single heart, but separation was done at Philadelphia where one twin died at surgery ten weeks later the other also died. Professor Ignazio Marino of Italy refused to operate in a similar case for identical reasons. Although the medical judgment, that without separation both twins would die within six months could be correct, there are many examples of conjoined twins who had not been separated and who had lead contented lives. It is not possible to find any justifiable reason as to why the parents' wishes had not been honoured. Even the legal judgments did not order the doctors to perform an operation; they only gave them permission to do so against the parents' wishes. Had St. Mary's acceded to the parents wishes, without taking recourse to the Courts, no one would have criticized them for letting nature take its course in accordance with the parents' wishes. In this connection the Archbishop of Westminster, The Most Reverend Cormac Murphy-O'Connor made five submissions based on Roman Catholic faith and morality. "First, human life is sacred and inviolable. Secondly, a person's bodily integrity should not be invaded when that can confer no benefit. Thirdly, the duty to preserve one person's life cannot without grave injustice be effected by a lethal assault on another. Fourthly, there is no duty on doctors to resort to extraordinary means in order to preserve life. Fifthly, the rights of parents should be overridden only where they are clearly 'contrary to what is strictly owing to their children." It cannot be gainsaid that these observations of the Archbishop are entitled to profound respect; nevertheless, they do not clarify the teachings in respect of Roman Catholic moral theology's teachings regarding the doctrine of double effect2. Some people expressed the opinion, in this regard, that it is surely morally mistaken to assume that choosing the lesser of the two evils involves the killing one child in order to save the other, because in the alternative both the children will die; for the alternative "lesser of two evils" is to allow both to die-as in the common rejection of killing that the thought experiment makes clear-rather than deliberately to kill one child in order to save another3. The legal issues raised are discussed next. In Airedale N.H.S. Trust v Bland in House of Lords, Lord Browne-Wilkinson gave a judgment which was at the same time excellent and most instructive in respect euthanasia. In this case, withdrawal of life support systems was permitted4. In UK, the Courts have held that the common law permits every person to decide for themselves, whether to agree to have surgery or medicine and that this right implies a right to refuse the same even if such refusal results in death. The Court of Appeal was in concurrence to this position as depicted in Re T, regarding refusal of medical treatment5. In this case the patient had refused blood transfusion on religious grounds. The British Law Commission has also made various proposals on the basis of functional approach, and has gone into the method and manner of testing a patient's incapacity to take a decision. It recommended the constitution of a Court with jurisdiction to deal with financial, personal welfare and healthcare methods instead of the present Court of Protection which deals only with financial matters. Whether euthanasia or assisted suicide should be legalised is one of the most pressing and profound questions facing legislators, health-care professionals, their patients and in reality all members of society. The Appeal Court judgment reveals a lacuna in that such a rare case was not referred to the House of Lords, particularly as it had set dangerous legal precedents which could have sinister implications in the future. In respect of the Archbishop of Westminster's observations the legal position is that the law is only concerned with what is legal and what is illegal. Further, from this case a moral dilemma, as discussed in the ethical issues involved, has emerged. The high court judge concluded that "to prolong Mary's life for these few months would be very seriously to her disadvantage". The Appeal Court said that the High Court Judge "was wrong to find it [Mary's life] was worth nothing". They also said that he "erred in his finding that to prolong Mary's life would be seriously to her disadvantage." They also dismissed his argument about calling the operation 'treatment' for Mary and so dismissed his use of the Tony Bland judgement to state that cutting the aorta (supplying Mary) would be the same as removing 'treatment' - i.e. food and fluids in Tony Bland's case. After having effectively destroyed each one of the arguments which the original High Court judge had used to justify the carrying out of the operation against the parents' wishes, the Appeal Court managed to arrive at the same conclusion and in essence support the original judgment. Lord Justice Ward concluded that "Though Mary has a right to life, she has little right to be alive. She is alive because and only because to put it bluntly but nonetheless accurately she sucks the lifeblood of Jodie and her parasitic living will soon be the cause of Jodie ceasing to live. Jodie is entitled to protest that Mary is killing her. Nobody but the doctors can help Jodie. Mary sadly is beyond any help... I am wholly satisfied that the least detrimental choice is to permit separation to take place." After opining in this manner Lord Justice Ward made a vital proviso, namely, "But it remains subject to the analysis of whether the operation is lawful." In order to resolve this dilemma he took recourse to the Bland judgment and held forth that in that case the doctors were fully aware of the fact that death would ensue from their actions and that the House of Lords had upheld the legality of their treatment. The summary states that, "If so the doctors intend in law to kill even though they may not have any desire to achieve that result. On the basis of that test the ingredient of intention as an element of murder is established." This is a statement which should be cause for concern. Further, it was stated in the summary that, " the appeal turns upon the crucial and difficult question of whether the doctors would be able in law to justify or excuse their conduct." ... "The reality here, harsh as it is to state it and unnatural as it is that it should be happening, is that Mary is killing Jodie." The judge argued that the doctors were acting in 'self-defense' for Jodie against Mary, by killing Mary. In this case Lord Justice Brooke made the following observations; first, Mary was to be considered a human being as per the law. Second, the operation was nothing but the killing of Mary. Third, the doctors could be held to have the intention of killing Mary. Fourth, the doctrine of double effect, which empowers a doctor, acting in good faith, to administer pain-killing drugs to a dying patient is not germane to this case. Fifth, Mary's brain, heart and lungs were not functioning. Sixth, the principles of modern family require that the interests of Jodie must be given preference over those of Mary, therefore, as the three requirement for the arguments of necessity are satisfied in this case, the judge held that the operation would give their bodies the integrity which nature had denied them. Therefore he also dismissed the appeal. In this respect, Lord Justice Ward held forth that, Describing the two alternatives in terms of choosing between the lesser of two evils on the one hand, and the obligation not to kill on the other, Lord Justice Ward declared that, "Parents who were placed on the horns of such a terrible dilemma simply had to choose the lesser of their inevitable loss". After a careful consideration of the interests of each child, consequent, to the operation being carried out or not, the judges held that while it was in the best interests of the weaker twin, not to be killed by the operation; it was also in the best interests the stronger twin that the operation should be carried out. Under such circumstances, they decided, "there was no other way of dealing with it than by choosing the lesser of the two evils and so finding the least detrimental alternative". The only way out is to adopt the Judith Jarvis Thomson's famous violinist argument. Judith never asked for Mary to be attached to her heart and lungs and should be allowed to be disconnected from her blood sucking, parasite, sister, who was not only compromising her bodily integrity and human dignity, but was shortly going to kill her. On this basis Mary was to be seen as an aggressor whom it was justifiable for Judith or her proxies to kill. If that was the reasoning the judges ought to have spelt it out, but of course it is by no means clear cut or uncontentious an argument. Although Lord Justice Ward explicitly stated that the Court of Appeal's judgment could not constitute authorization for a doctor to kill a patient, once the doctor had decided on the basis of the medical requirements of that particular case, that the patient could not survive, it is natural to extend this reasoning to separate children as much as it was applicable to conjoined children. It was held in this case that the judgment had necessarily been rather technical, and that some of the issues seemed to be rather isolated from the dilemma which Jodie's and Mary's condition presented. It was decided in accordance with the principles of existing law as applicable to the facts of the case. The conclusions of the judge were, first, the feelings of the twins' parents were entitled to great respect, especially so far as they were based on religious convictions and the best interests of the twins was to be taken into account. Secondly, the lower court judge erred in law by equating the proposed surgical operation with the discontinuance of medical treatment. Thirdly, Mary had a right to life, as provided for by the common law of England and the European Convention on Human Rights. It would therefore be against the law to undertake an operation, intentionally, whereby Mary would lose her life. Fourthly, Jodie also has a right to life. Fifthly, it is intrinsic that every human being's right to life includes the right of bodily integrity and autonomy or in other words the right to have one's own body whole and intact. Sixthly, a rare misfortune had deprived both Mary and Jodie of this bodily integrity and autonomy which is their natural right. Seventhly, the purpose of the operation would be to separate the twins and thereby enable Jodie a reasonably good prospect of a long and reasonably normal life. Eighthly, continued life, would bestow on Mary nothing except possible pain and discomfort in the event that she could feel any such thing. Ninthly, the proposed operation would serve the best interests of each of the twins and therefore, the decision did not require the court to value one life above another. Finally, this would be legal and would involve the benefit of invasive surgery, whereby Mary's death would be construed as inevitable in order to save Jodie's life. Hence, the parents' appeal was dismissed. The medical and legal ethics of conjoined twins present an interesting and controversial debate. On one hand parents should be free to make difficult medical decisions for their minor children without question by the courts. On the other hand, if a child can be saved with medical attention, the child should have the opportunity to receive treatment. The entire situation is complicated by issues of religion, cost, uncertain outcomes and inherent differences. No parent wants to make this difficult decision, where if one child is not chosen to live then both die. Innovative operations such as this one are fraught with ethical worries. However, several ethicists were of the opinion that the doctors who had performed the failed surgery in Singapore had not violated the requirements of ethicality as they had assembled a group of highly trained doctors to envisage any reasonable setback during the procedure. Further, they had made absolutely sure that the patients were aware of the near fatal nature of the treatment. In respect of Jodie and Mary, it became unavoidable to compare the right of each of the twins to life and while doing so it became essential to consider their actual physical condition and the loss or gain from the treatment. This was the critical juncture or turning point in according a greater right to live to Jodie in comparison to Mary. In conclusion, the consequences of this decision have to be noted, they are, first, sound and fair decisions made by caring and loving parents in conformity to their religious beliefs can be set aside by the courts. Secondly, the opinion of doctors are to be presumed to be sacrosanct and the Courts will support this contention and thirdly, a life can be taken if this benefits another life. Bibliography. 1. Diesfeld, K and Freckleton, I (2003), Involuntary Detention and Therapeutic Jurisprudence, International Perspectives on Civil Commitment (Dartmouth: Ashgate). 2. Fennell, P (1996) Treatment Without Consent: Law, Psychiatry and the Treatment of Mentally Disordered People Since 1845 (London: Routledge) [KJ109 .M3F3]. 3. Glover-Thomas, N (2002), Reconstructing Mental Health Law and Policy (London: Sweet & Maxwell) [KM20 .G5]. 4. Jonathan Moreno (1995). Arguing Euthanasia: The Controversy Over Mercy Killing, Assisted Suicide, And The "Right To Die". (Touchstone. ISBN: 0684807602). 5. Michael Manning (1998). Euthanasia and Physician - Assisted Suicide.(Paulist Press. ISBN: 0809138042). Read More